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Lecture notes, cheat sheets
Obstetrics and gynecology. Intrauterine fetal death. Fruit-destroying operations (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) Lecture No. 27. Intrauterine fetal death. Fruit-destroying operations 1. Intrauterine fetal death Intrauterine fetal death is the death of a fetus during pregnancy or childbirth. Fetal death during pregnancy refers to antenatal mortality, death during childbirth - intrapartum death. The causes of antenatal fetal death can be infectious diseases of a pregnant woman (flu, typhoid fever, pneumonia, pyelonephritis, etc.), extragenital diseases (congenital heart defects, hypertension, diabetes mellitus, anemia, etc.), inflammatory processes in the genitals. The cause of fetal death can be severe OPG-preeclampsia, pathology of the placenta (malformations of its development, presentation, premature detachment) and the umbilical cord (true node), entanglement of the umbilical cord around the fetal neck, oligohydramnios, multiple pregnancy, Rh incompatibility of the blood of the mother and fetus. Fetal death in the intranatal period, in addition to the above reasons, may be associated with traumatic brain injury and damage to the fetal spine during childbirth. The immediate cause of fetal death is most often intrauterine infection, acute and chronic hypoxia, fetal malformations incompatible with life. Sometimes it is not possible to find out the cause of intrauterine death. A dead fetus can stay in the uterine cavity for a long time (from several days to several months) and undergo maceration, mummification or petrification in utero. Most often, maceration occurs (putrefactive wet necrosis of tissues), usually accompanied by autolysis of the internal organs of the fetus. In the first days after the death of the fetus, aseptic maceration occurs, then an infection joins, which can lead to the development of sepsis in a woman. The macerated fruit has a characteristic flabby appearance, soft texture, reddish skin, wrinkled with exfoliated epidermis in the form of bubbles. When infected, the skin turns green. The head of the fetus is soft, flattened, with severed skull bones. The chest and abdomen also have a flattened shape. Congenital atelectasis of the lungs is a reliable sign of intrauterine fetal death. Clinical manifestations of antenatal death of the fetus are the cessation of growth of the uterus, the disappearance of engorgement of the mammary glands. A woman complains of malaise, weakness, a feeling of heaviness in the abdomen, and the absence of fetal movements. During the examination, there is a decrease in the tone of the uterus and the absence of its contractions, palpitations and fetal movements. A sign of intranatal fetal death is the cessation of his heartbeat. If antenatal fetal death is suspected, the pregnant woman is urgently hospitalized for examination. Reliably the diagnosis of fetal death is confirmed by the results of FCG and ECG of the fetus, which register the absence of cardiac complexes, and ultrasound. Ultrasound in the early stages after the death of the fetus determines the absence of his respiratory activity and heartbeat, fuzzy contours of his body, in the later stages, the destruction of body structures is determined. In case of antenatal fetal death in the first trimester of pregnancy, the fetal egg is removed by scraping the uterine cavity. With the death of the fetus in the II trimester of pregnancy and with premature detachment of the placenta, urgent delivery is required. In this case, the method of delivery is determined by the degree of readiness of the birth canal. In the absence of indications for urgent delivery, a clinical examination of the pregnant woman is carried out with a mandatory study of the blood coagulation system, then labor induction is started, creating an estrogen-glucose-vitamin-calcium background for 3 days, after which the administration of oxytocin, prostaglandins is prescribed. In order to accelerate the first stage of labor, an amniotomy is performed. With antenatal death of the fetus in the third trimester of pregnancy, childbirth, as a rule, begins on its own. In case of intranatal fetal death, according to indications, fruit-destroying operations are performed. Fruit-destroying operations (embryotomies) are obstetric operations in which the fetus is dissected in order to facilitate its extraction through the natural birth canal. As a rule, such operations are carried out on a dead fetus. On a live fetus, they are permissible only as a last resort, if it is impossible to give birth through the natural birth canal, with fetal deformities (severe hydrocephalus), severe complications of childbirth that threaten the life of the woman in labor, and in the absence of conditions for delivery by surgery, allowing to save the life of the fetus. Fruit-destroying operations are possible only with full or almost complete opening of the uterine os, true conjugate of the pelvis is more than 6,5 cm. In these operations, the method of choice of anesthesia is short-term endotracheal anesthesia. Fruit-destroying operations include craniotomy, decapitation, evisceration (exenteration), spondylotomy, and cleidotomy. 2. Craniotomy Craniotomy is the operation of breaking the integrity of the fetal skull. Indications for craniotomy are a significant discrepancy between the size of the pelvis of the pregnant woman and the fetal head (hydrocephalus), unfavorable presentation of the fetus (frontal, anterior facial view), threatening uterine rupture, infringement of the soft tissues of the birth canal, the serious condition of the woman in labor, requiring immediate delivery or acceleration of labor, the inability to extract subsequent head during childbirth in breech presentation. Craniotomy consists of three stages: perforation (perforation) of the fetal head, destruction and removal of the brain (excerebration) with subsequent extraction of the fetus. Perforation is performed using a perforator (spear-shaped - Blo or trepan-shaped - Fenomenov). Using a large curette, the brain is destroyed and scooped out (excerbation). The destroyed brain can also be removed by washing out with a sterile solution introduced into the cranial cavity through a catheter, or by vacuum suction. For the operation of craniotomy, you can use a device designed by I. A. Sytnik et al. This device allows you to perform all stages of the operation. It is inserted into the vagina under the control of vision and fingers. A special screw is used to perforate and destroy the substance of the brain, which is sucked off using a vacuum apparatus, after which the reduced head is easily removed. The use of this device makes it possible to exclude the possibility of damage to the birth canal of a woman both with the instrument and the bones of the fetal head. 3. Decapitation Decapitation - separation of the head of the fetus from the body (decapitation). The indication is the running transverse position of the fetus. The operation is performed with a complete or almost complete opening of the uterine os, the absence of a fetal bladder, and the availability of the fetal neck for the obstetrician's hand. Decapitation is carried out with a Brown decapitation hook, consisting of a massive metal rod bent at one end in the form of a hook, ending in a button-like thickening. The other end is a handle that looks like a massive crossbar. A Brown hook applied to the neck of the fetus produces a fracture of the spine, and the head is separated from the body with scissors. Sipping on the handle of the fetus, the torso is removed from the uterus, and then the head is removed. I. A. Sytnik and co-authors designed an instrument (decapitator) that makes it possible to perform all stages of the operation less traumatically. 4. Cleidotomy Cleidotomy - dissection of the clavicle of the fetus. The operation is performed only on a dead fetus in cases where it is difficult to remove the shoulder girdle of the fetus due to the large size of the shoulders, a clinically narrow pelvis. The shoulders linger in the birth canal and thereby suspend the birth of the fetus. Most often, such a complication occurs with a breech presentation, but it can also occur with a headache. 5. Evisceration When the transverse position is running, if it is impossible to separate the fetal head from the body, evisceration is performed - the removal of the internal organs of the fetus. It is performed after a preliminary dissection of the abdominal wall or chest of the fetus. 6. Spondylotomy If, after evisceration, it is not possible to extract the fetus, then a spondylotomy is performed - dissection of the fetal spine in the thoracic or abdominal region. In the production of fruit-destroying operations, there is a high probability of complications associated with the slippage of sharp instruments that are used to produce them. As a result, injuries to the internal genital organs, as well as the rectum and bladder, can occur. To prevent possible injuries, one should strictly observe the caution and technique of performing the operation, and perform all manipulations, if possible, under visual control. Anesthesia should be deep enough to exclude the motor activity of the woman in labor. After carrying out fruit-destroying operations, after the birth of the placenta, a manual examination of the walls of the uterus is mandatory, the vagina and cervix are examined using vaginal mirrors in order to establish their integrity. Bladder catheterization eliminates the presence of damage to the urinary system. Author: Ilyin A.A. << Back: Pregnancy is multiple
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